Registration Form for New Patients (Children)

Please complete in BLOCK CAPITALS, and tick the boxes as appropriate:

Sex:  				Male  □      			 			Female □     	
First Name: 		Preferred Name:		
Surname:			
Date of Birth:			
Home Address:		

Postcode:		
Home Telephone Number:		
Mobile Telephone Number:		
NHS Number:		
Place of Birth	Town		
	County		
	Country		

Has your child ever been at this surgery before:	Yes		No		
If your child has previously registered with a GP on the NHS:	Yes		No		
Name and address of previous GP:		

Your previous address and postcode while registered with previous GP:		

Postcode:		
		
If returning from abroad:		
Date left the UK if previously a resident of the UK:		
Date first came to live in the UK:		
First UK address:		

		

Health Questionnaire:
It often takes a few weeks to get your records from your previous GP. It would be helpful if you could answer the following questions so that we have some background knowledge of your health. Thank you.

Please list any serious illness, operations or long-term health problems (EG: diabetes, blood pressure) that require medication:

		

		
Please List your current medications:		
Medication:	Dose:	

		
Drug Allergies:		

Next of kin:
Name		
Address		
Relationship
		
Telephone No		
Mobile No		
Email Address		
Emergency contact		Yes / No	
Can discuss record	Yes / No	

Ethnicity
The Government requires us to collect data about the ethnic background of our patients. This information can help the Department of Health plan to meet the needs of the community and ensure that everyone has equal access to healthcare.Please note that we are not asking about citizenship or nationality but about the ethnic group to which you feel that you belong.

All the information we receive will be used and treated with confidence. All information released is CONFIDENTIAL and anonymous.

Completing this form is entirely voluntary. Your care at the surgery will not be affected by your decision to complete or not complete this form. If you have any questions about completing this form, please ask a member of staff. Otherwise, please complete the from below by ticking the box of the ethnic group you feel you belong to. If you feel you are descended from more than one group, please tick the one you feel you most belong to, or choose the “Any other ethnic group” box.

AO	White	British		
BO	White	Irish		
CO	White	Any other white background		
DO	Mixed	White and Black Caribbean		
EO	Mixed	White and Black African		
FO	Mixed	White and Asian		
GO	Mixed	Any other mixed background		
HO	Asian or British Asian	Indian		
JO	Asian or British Asian	Pakistani		
KO	Asian or British Asian	Bangladeshi		
LE	Asian or British Asian	Sri Lankan		
LO	Asian or British Asian	Any other Asian background		
MO	Black	Caribbean		
NO	Black	African		
PO	Black	British		
PD	Black	Any other Black background		
RO	Other ethnic groups	Chinese		
SO	Other ethnic groups	Any other ethnic group		

Main Language:		

Is there any additional information that you would like to make us aware of?